Basic Information
| Provider Information | |||||||||
| NPI: | 1679688675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | INGRAM | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALE | ||||||||
| OtherFirstName: | BRENDA | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 115 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | SULPHUR SPRINGS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754822105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038857671 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 02/10/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA03143 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P01761904 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 75-2616977-002 | 01 | TX | TRICARE | OTHER | 75-2616977-129 | 01 | TX | TRICARE | OTHER | 8478MA | 01 | TX | BCBS | OTHER | 313744004 | 05 | TX | MEDICAID | 313744006 | 05 | TX | MEDICAID | 75-2616977-001 | 01 | TX | TRICARE | OTHER | 8479MA | 01 | TX | BCBS | OTHER | P01762486 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 75-0818167-015 | 01 | TX | TRICARE | OTHER | 75-0818167-044 | 01 | TX | TRICARE | OTHER | 75-0818167-048 | 01 | TX | TRICARE | OTHER | 75-2616977-028 | 01 | TX | TRICARE | OTHER | 313744005 | 05 | TX | MEDICAID | 75-0818167-022 | 01 | TX | TRICARE | OTHER | 75-1976930-005 | 01 | TX | TRICARE | OTHER | 313744007 | 05 | TX | MEDICAID |